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Preventing and Treating Orthostatic Hypotension: As Easy As A, B, C

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Preventing and Treating Orthostatic Hypotension: As Easy As A, B, C REE VI W CME EDUCATIONAL OBJECTIVE: Readers will teach their patients to avoid episodes of orthostatic hypotension CREDIT JUAN J. FIGUEROA, MD JEF F REY R. BASFORD, MD, PhD PHILLI P A. LOW, MD Department of Neurology, Mayo Department of Physical Medicine and Rehabili- Department of Neurology, Mayo Clinic, Clinic, Rochester, MN tation, Mayo Clinic, Rochester, MN Rochester, MN Preventing and treating orthostatic hypotension: As easy as A, B, C ■ ABSTRT AC rthostatic hypotension is a chronic, O debilitating illness associated with com- Orthostatic hypotension is a chronic, debilitating illness mon neurologic conditions (eg, diabetic neu- that is difficult to treat. The therapeutic goal is to im- ropathy, Parkinson disease). It is common in prove postural symptoms, standing time, and function the elderly, especially in those who are institu- rather than to achieve upright normotension, which can tionalized and are using multiple medications. lead to supine hypertension. Drug therapy alone is never Treatment can be challenging, especially if the problem is neurogenic. This condition adequate. Because orthostatic stress varies with circum- has no cure, symptoms vary in different cir- stances during the day, a patient-oriented approach that cumstances, treatment is nonspecific, and ag- emphasizes education and nonpharmacologic strategies gressive treatment can lead to marked supine is critical. We provide easy-to-remember management hypertension. recommendations, using a combination of drug and non- This review focuses on the prevention and drug treatments that have proven efficacious. treatment of neurogenic causes of orthostatic hypotension. We emphasize a simple but ef- ■ KEY POINTS fective patient-oriented approach to manage- ment, using a combination of nonpharmaco- Treatment is directed at increasing blood volume, de- logic strategies and drugs clinically proven creasing venous pooling, and increasing vasoconstriction to be efficacious. The recommendations and while minimizing supine hypertension. their rationale are organized in a practical and easy-to-remember format for both physicians Patient education and nondrug strategies alone can be and patients. effective in mild cases. Examples: consuming extra fluids and salt, wearing an abdominal binder, drinking boluses ■ WHAT HAPPENS WHEN WE STAND UP? of water, raising the head of the bed, and performing countermaneuvers and physical activity. When we stand up, the blood goes down from the chest to the distensible venous capaci- Moderate and severe cases require additional drug treat- tance system below the diaphragm. This fluid ment. Pyridostigmine (Mestinon) is helpful in moderate shift produces a decrease in venous return, ventricular filling, cardiac output, and blood cases. Fludrocortisone (Florinef) and midodrine (ProAma- pressure.1 tine) are indicated in more severe cases. This gravity-induced drop in blood pres- sure, detected by arterial baroreceptors in the aortic arch and carotid sinus, triggers a com- pensatory reflex tachycardia and vasoconstric- doi:10.3949/ccjm.77a.09118 tion that restores normotension in the upright 298 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • NUMBER 5 MAY 2010 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. FIGUEROA AND COLLEAGUES position. This compensatory mechanism is be due to neuropathy (eg, diabetic or autoim- termed a baroreflex; it is mediated by affer- mune neuropathies) or to central lesions (eg, ent and efferent autonomic peripheral nerves Parkinson disease or multiple system atrophy). and is integrated in autonomic centers in the Its presence, severity, and temporal course can brainstem.2 be important clues in diagnosing Parkinson Orthostatic hypotension is the result of disease and differentiating it from other par- baroreflex failure (autonomic failure), end- kinsonian syndromes with a more ominous organ dysfunction, or volume depletion. Injury prognosis, such as multiple system atrophy to any limb of the baroreflex causes neurogenic and Lewy body dementia. orthostatic hypo tension, although with affer- Nonneurogenic causes include cardiac im- ent lesions alone, the hypotension tends to be pairment (eg, from myocardial infarction or modest and accompanied by wide fluctuations aortic stenosis), reduced intravascular volume in blood pressure, including severe hyperten- (eg, from dehydration, adrenal insufficiency), sion. Drugs can produce orthostatic hypoten- and vasodilation (eg, from fever, systemic mas- sion by interfering with the autonomic path- tocytosis). ways or their target end-organs or by affecting Common drugs that cause orthostatic intravascular volume. Brain hypoperfusion, hypo tension are diuretics, alpha-adrenoceptor resulting from orthostatic hypotension from blockers for prostatic hypertrophy, antihyper- any cause, can lead to symptoms of orthostatic tensive drugs, and calcium channel blockers. intolerance (eg, lightheadedness) and falls, and Insulin, levodopa, and tricyclic antidepres- if the hypotension is severe, to syncope. sants can also cause vasodilation and ortho- static hypotension in predisposed patients. ■ A DECREASE OF 20 MM HG SYSTOLIC Poon and Braun,6 in a retrospective study in OR 10 MM HG DIASTOLIC elderly veterans, identified hydrochlorothia- zide, lisinopril (Prinivil, Zestril), trazodone The consensus definition of orthostatic hypo- (Desyrel), furosemide (Lasix), and terazosin tension is a reduction of systolic blood pressure (Hytrin) as the most common culprits. of at least 20 mm Hg or a reduction of diastolic R ecurrent or blood pressure of at least 10 mm Hg within 3 ■ ORTHOSTATIC HYPOTENSION unexplained minutes of erect standing.3 A transient drop IS COMMON IN THE ELDERLY that occurs with abrupt standing and resolves falls in older rapidly suggests a benign condition, such as de- The prevalence of orthostatic hypotension is adults may be a hydration, rather than autonomic failure. high in the elderly and depends on the charac- manifestation In the laboratory, patients are placed on a tilt teristics of the population studied, such as age, table in the head-up position at an angle of at use of medications, and comorbidities known of syncope due least 60 degrees to detect orthostatic changes in to be associated with this problem. Ortho- to orthostatic blood pressure. In the office, 1 minute of stand- static hypotension is more common in insti- ing probably detects nearly all cases of ortho- tutionalized elderly people (up to 68%)7 than hypotension static hypotension; however, standing beyond in those living in the community (6%).8 The 2 minutes helps establish the severity (a further high prevalence among institutionalized pa- drop in blood pressure).4 Orthostatic hypoten- tients likely reflects multiple disease processes, sion developing after 3 minutes of standing is including neurologic and cardiac conditions, uncommon and may represent a reflex presyn- as well as medications associated with ortho- cope (eg, vasovagal) or a mild or early form of static hypotension. sympathetic adrenergic dysfunction.4, 5 ■ CLINICAL MANIFESTATIONS ARE DUE TO ■ NEUROGENIC AND HYPOPERFUSION, OVERCOMPENSATION NONNEUROGENIC CAUSES Symptoms are related to cerebral hypoperfu- Orthostatic hypotension may result from neu- sion, with resulting lack of cerebral oxygen- rogenic and nonneurogenic causes. ation (causing lightheadedness, dizziness, Neurogenic orthostatic hypotension can weakness, difficulty thinking, headache, syn- CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • NUMBER 5 MAY 2010 299 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. O RTHOSTATIC HYPOTENSION but subtler issues such as difficulty thinking, TABLE 1 weakness, and neck discomfort are also com- T reatment of orthostatic hypotension mon in the elderly. Recurrent or unexplained in special circumstances falls in older adults may be a manifestation of syncope due to orthostatic hypotension. O rthostatic decompensation (more severe or less responsive to pressor agents) ■ PROGNOSIS DEPENDS ON CAUSE Consider aggravating conditions such as anemia, hypovolemia, heart failure, deconditioning. Orthostatic hypotension is a syndrome, and Salty soups and about five 8-ounce servings of fluid over half a day, its prognosis depends on its specific cause, its if acute, or: severity, and the distribution of its autonomic Salt tablets 2 g three times a day with a minimum of eight 8-ounce and nonautonomic involvement. In patients servings of fluid over 1 day. who have extrapyramidal and cerebellar dis- Fludrocortisone (Florinef) 0.2 mg three times a day for 1 week. orders (eg, Parkinson disease, multiple system During this time, an abdominal binder can be useful. atrophy), the earlier and the more severe the involvement of the autonomic nervous sys- If severe, provide acute hospital management with intravenous tem, the poorer the prognosis.9,10 fluid expansion. In hypertensive patients with diabetes mel- Early morning orthostatic hypotension litus, the risk of death is higher if they have or- Instruct patients to: thostatic hypotension.11 Diastolic orthostatic Be careful on awakening hypotension is associated with a higher risk of Elevate the head of the bed (reducing nocturia) vascular death in older persons.12 Drink two cups of cold water 30 minutes before arising Shift from supine to an erect position in gradual stages. ■ MANAGEMENT: FROM A TO F Postprandial orthostatic hypotension (common in patients with diabetic neuropathy) The
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